DSM-5 Diagnostic Approaches - Amazon Web...

25
www.mghcme.org DSM-5 Diagnostic Approaches to Autism Spectrum Disorder Bennett L. Leventhal, MD Professor, Department of Psychiatry STAR Center for ASD and NDD’s University of California, San Francisco

Transcript of DSM-5 Diagnostic Approaches - Amazon Web...

www.mghcme.org

DSM-5 Diagnostic Approaches

to

Autism Spectrum Disorder

Bennett L. Leventhal, MD Professor, Department of Psychiatry

STAR Center for ASD and NDD’s University of California, San Francisco

www.mghcme.org

Disclosures

• Research Support

– Janssen – study completed

– NIH

• Consulting

– Janssen – non-pharmacological research project

www.mghcme.org

What is a Neurodevelopmental Disorder?(1)

–Usually Syndromal

–Pediatric Onset

–Affecting Brain Function

–Clinical Effects on

• Emotion

•Cognition

•Behavior

www.mghcme.org

What is a Neurodevelopmental Disorder? (2)

• Etiology

– Usually a genetic component

– Often Familial

– Sometimes heritable

– May be related to de novo events

– Role for epigenetics

– Role for Gene-Environment Interactions (GEX)

www.mghcme.org

What is a Neurodevelopmental Disorder? (3)

1. Intellectual Disability (ID)

(Intellectual Development Disorder)

2. Global Development Delay

3. Unspecified Intellectual Disability

(Intellectual Developmental Disorder)

4. Language Disorder

5. Speech Sound Disorder

6. Childhood-Onset Fluency Disorder

(Stuttering)

7. Social Pragmatic Communication

Disorder (SCD)

8. Unspecified Communication Disorder

9. Autism Spectrum Disorder(ASD)

10. Attention Deficit Hyperactivity Disorder

(ADHD)

11. Other Specified Attention-Deficit Hyperactivity Disorder

12. Unspecified Attention-Deficit Hyperactivity Disorder

13. Specific Learning Disorder

14. Developmental Coordination Disorder

15. Stereotypic Movement Disorder

16. Tic Disorder

17. Other Specified Tic Disorder

18. Unspecified Tic Disorder

19. Other Specified Neurodevelopmental Disorder

20. Unspecified Neurodevelopmental Disorder

per DSM5

www.mghcme.org

What is a Neurodevelopmental Disorder? (4)

Consider Other Neurodevelopmental Disorders: OCD Eating Disorders Mood Disorders

Bipolar Disorder Major Depressive Disorder

Substance Abuse Schizophrenia Trauma related disorders Epilepsy Alzheimer’s Disease

www.mghcme.org

Autism/ASD – A Syndrome

• Syndrome – Group of symptoms that tend to cluster together and

share a common natural history/course

• Disease – A syndrome for which there is either:

• A known etiology (or cause)

• A known pathophysiological process

• Both

• ASD is not so unusual because: – Like the most medical conditions, ASD is a syndrome

www.mghcme.org

Leo Kanner (1894-1981)

“Autistic Disturbances of Affective Contact”

The Nervous Child, 1943

www.mghcme.org

Autism Spectrum Disorders (ASD)

The 2 “D’s” = Delay & Deviations Domains of Impairment

a. Social/Communication Development • Joint Attention • Theory of Mind • Reciprocity • Expressive/Receptive Language

b. Restricted/Repetitive & Stereotyped Patterns of Interests and Activities (including IS)

www.mghcme.org

Autism & Autistic Spectrum Disorders (ASD)

• Course a. Consistent over time

b. Some symptoms decrease a. Stereotypies

b. Visual regard

c. Some symptoms persist - Lack of social reciprocity

- Language abnormalities

- Restrictive and repetitive behaviors/IS

www.mghcme.org

NSAC Criteria 1978

A. Disturbed rate &/or sequence of development

B. Disturbed response to sensory stimuli

C. Disturbed speech/language, cognitive development

D. Disturbed Quality to relate appropriately to people, events and objects

www.mghcme.org

DSM-IV Pervasive Developmental Disorders (PDD)

299.0 Autistic Disorder

299.8 Asperger’s Disorder

299.9 Rett’s Syndrome

299.1 Childhood Disintegrative Disorder

299.8 Pervasive Developmental Disorder, Not Otherwise Specified (PDD-NOS)

www.mghcme.org

DSM-IV Autism Spectrum Disorders

Deficits

Dx

Reciprocal

Social

Language Cognitive Repetitive,

Restricted

Autism + + +/- +

Aspergers + - - +

PDD-NOS + +/- +/- +

www.mghcme.org

DSM 5: ASD

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays

B. Restricted, repetitive patterns of behavior, interests, or activities

C. Symptoms must be present in early childhood

D. Symptoms together limit and impair everyday functioning.

www.mghcme.org

DSM-IV >> DSM-5 Summary

A. Delay and/or abnormal patterns of development before age 3

B. Qualitative impairment in reciprocal social interactions

C. Qualitative impairments in communication

D. Restricted, repetitive and stereotyped patterns of behavior, interests and activities

A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays

B. Restricted, repetitive patterns of behavior, interests, or activities

C. Symptoms must be present in early childhood

D. Symptoms together limit and impair everyday functioning.

www.mghcme.org

DSM-IV/DSM-5 Asperger Comparison

Similar cross-over, for example: A. Qualitative Impairments in Social Interaction >>>A B. Restricted, repetitive, and stereotyped patterns of

behavior, interests, and activities, as manifested by at least one of the following:

• encompassing preoccupation with one or more stereotyped and restricted patterns of interest that is abnormal either in intensity or focus >>>B1

• apparently inflexible adherence to specific, nonfunctional routines or rituals >>>B2

• stereotyped and repetitive motor mannerisms (e.g., hand or finger flapping or twisting, or complex whole-body movements)>>>>B1

• persistent preoccupation with parts of objects >>>B3

www.mghcme.org

DSM 5 Social Communication Disorder

A. Social Communication Disorder (SCD)is

– an impairment of pragmatics

– diagnosed based on difficulty in the social uses of

verbal and nonverbal communication

B. Low social communication abilities

– result in functional limitations

C. Rule out Autism Spectrum Disorder

D. Symptoms must be present in early childhood

www.mghcme.org

www.mghcme.org

Prevalence Estimates: DSMIV PDD, DSM5 ASD, DSM5 SCD

% DSMIV PDD % DSM5 ASD % DSM5 SCD %DSM5 ASD+SCD

Population

Total 2.64 2.20 0.49 2.69

GPS 1.89 1.46 0.49 1.95

Clinical 0.75 0.75 0.00 0.76

DSMIV PDD Subtype

Austistic Dis 1.04 1.03 0.001 1.04

Asperger 0.60 0.55 0.05 0.59

PDD-NOS 1.00 0.63 0.32 0.94

www.mghcme.org

DSMIV cases not meeting DSM5 Criteria

Divergent Group, n=22 (7.5%)

% of Divergent

% Total

Other Diagnoses

SCD 14 64 4.8

SCD+other Psych Disorder

4 14 1.4

Other Psych Disorder

5 22 1.7

No Diagnosis 0 0 0

www.mghcme.org

So, will people be left out?

• Will patients with DSM-IV Pervasive Developmental Disorder not meet DSM-5 criteria? – YES

• A few ~ 3% • Rett’s Syndrome - All • Autistic Disorder - None • Aspergers - very few

– > SCD

• PDD-NOS – > SCD (most) – > Other Psychiatric Disorder - ? did not have PDD in the first place

» ADHD & Anxiety Disorder

www.mghcme.org

Sources of Diagnostic Information

• Screening

• Clinical Interview

– History

– Direct Observation

• Standard Diagnostics

– ADI

– ADOS

– CARS

• Adaptive Function

– Vineland

– ABC

• Physical Examination

– Neurological

– Sensory Exam

• Laboratory

– Only as indicated

www.mghcme.org

Most children with ASD get better over time!

Our goals are:

Search for etiologies that can be used to

Enhance treatment

Prevent ASD

In the meantime:

Use treatments that improve the rate at which individuals with ASD acquire skills and the ability to use those skills for independent and semi-independent living

www.mghcme.org Donald Gray Triplett

www.mghcme.org

DSM-5 Diagnostic Approaches

to

Autism Spectrum Disorder

Bennett L. Leventhal, MD Professor, Department of Psychiatry

STAR Center for ASD and NDD’s University of California, San Francisco